Provider Demographics
NPI:1871753343
Name:MACGILLIVRAY, KIRK WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:WALTER
Last Name:MACGILLIVRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 S SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4038
Mailing Address - Country:US
Mailing Address - Phone:505-982-9700
Mailing Address - Fax:505-982-6465
Practice Address - Street 1:1496 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4038
Practice Address - Country:US
Practice Address - Phone:505-982-9700
Practice Address - Fax:505-982-6465
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist